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Provide Feedback to Front-Line Staff

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​Feedback to the front-line staff is a critical component of demonstrating a commitment to safety and ensuring that staff members continue to report safety issues. If the leadership acts upon suggestions, staff members should know their voices were heard and should be recognized for their contributions, especially when the leadership’s response would otherwise be invisible from the front lines. Maintaining a consistent flow of information from senior leadership affirms that every safety initiative is important and not a fleeting “idea of the month.”

Senior leaders conduct weekly WalkRounds to have informal conversations with front-line staff about safety issues and to demonstrate their support of an organizational culture that promotes nonpunitive reporting of errors, adverse events, near misses, and unsafe conditions.

November 17, 2016 | We like to think that robust safety cultures are so common in health care organizations today, everyone is comfortable pointing out missteps and discrepancies to their colleagues and even getting better at bringing them to the attention of their supervisors. Not so fast.

November 3, 2016 | Systems of safety, culture change, reliability, and a continuous learning system. These are not just theoretical concepts; they’re grounded in a lot of keen observations and careful work over many years and may be key to sustaining improvements in safety.

East London NHS Foundation Trust (ELFT) in the UK provides mental health and community services to a diverse and largely low-income population. By establishing an organization-wide culture of continuous improvement, and integrating quality improvement methodology and training at every level of work, ELFT has significantly reduced incidents of inpatient violence and improved staff satisfaction, among other achievements.

Watch videos of some of Don Berwick's most memorable IHI National Forum keynote addresses in which he talks about successes in health care quality improvement and the challenges that still lie ahead. Berwick uses his unique storytelling style to take his audiences around the world, highlighting innovations, demanding we protect patient safety, urging us to uncover waste and reduce costs in health care, and revealing the true meaning of patient-centered care.

This article reevaluates the status of patient safety improvements 15 years after "To Err Is Human" was published, noting there have been varying levels of improvement and effectiveness, and proposes a course for future patient safety work.